key: cord-0821861-se9swgvi
authors: Xiaoming, Xu; Ming, Ai; Su, Hong; Wo, Wang; Jianmei, Chen; Qi, Zhang; Hua, Hu; Xuemei, Li; Lixia, Wang; Jun, Cao; Lei, Shi; Zhen, Lv; Lian, Du; Jing, Li; Handan, Yang; Haitang, Qiu; Xiaoting, He; Xiaorong, Chen; Ran, Chen; Qinghua, Luo; Xinyu, Zhou; Jian, Tan; Jing, Tu; Guanghua, Jiang; Zhiqin, Han; Nkundimana, Baltha; Li, Kuang
title: The Psychological Status of 8817 Hospital Workers during COVID-19: a cross-sectional study in Chongqing
date: 2020-07-19
journal: J Affect Disord
DOI: 10.1016/j.jad.2020.07.092
sha: f505f9a0b3e5233713ef6a82bafd55427a82e55a
doc_id: 821861
cord_uid: se9swgvi

BACKGROUND: There was an outbreak of COVID-19 towards the end of 2019 in China, which spread all over the world rapidly. The Chinese healthcare system is facing a big challenge where hospital workers are experiencing enormous psychological pressure. This study aimed to (1) investigate the psychological status of hospital workers and (2) provide references for psychological crisis intervention in the future. METHOD: An online survey was conducted to collect sociodemographic features, epidemic-related factors, results of PHQ-9, GAD-7, PHQ-15, suicidal and self-harm ideation (SSI), and the score of stress and support scales. Chi-square test, t-test, non-parametric, and logistic regression analysis were used to detect the risk factors to psychological effect and SSI. RESULTS: 8817 hospital workers participated in this online survey. The prevalence of depression, anxiety, somatic symptoms, and SSI were 30.2%, 20.7%, 46.2%, and 6.5%, respectively. Logistic regression analysis showed that female, single, Tujia minority, educational background of junior or below, designated or county hospital, need for psychological assistance before or during the epidemic, unconfident about defeating COVID-19, ignorance about the epidemic, willingness of attending parties, and poor self-rated health condition were independent factors associated with high-level depression, somatic symptom, and SSI among hospital workers (P<0.05). LIMITATION: This cross-sectional study cannot reveal the causality, and voluntary participation could be prone to selection bias. A modified epidemic-related stress and support scale without standardization was used. The number of hospital workers in each hospital was unavailable. CONCLUSION: There were a high level of psychological impact and SSI among hospital workers, which needed to be addressed. County hospital workers were more severe and easier to be neglected. More studies on cognitive and behavioral subsequence after a public health disaster among hospital workers are needed

The coronavirus disease 2019 (COVID- 19) , a rapidly spread epidemic, has gained global attention since December 2019 . By January 29, 2020, all of the provinces in China have confirmed patients(Health Emergency Office，2020). Chongqing, a municipality directly under the central government, has a population of 31 million and borders Hubei on the east (The State Statistical Bureau, 2020). More than 70% of the 5 million people from Wuhan, who left for other cities during this Lunar spring festival, went to cities within Hubei province. However, Chongqing, among others, received the third-highest number of people (1.19%) from Wuhan between January 1 to 26, 2020, (Economic Observer, 2020) the peak duration of infection due to migration. Although Chongqing had begun the first-level response to major public health emergencies on January 24, 2020 (Chongqing Chan and Chan et al., 2004) . That was hard to fully understand the psychology impacts on hospital workers. Furthermore, COVID-19 was much "smarter" than the contagions we have ever met before, its quick spread, non-typical symptoms, and asymptomatic infection brought great stress on hospital workers on emotion, body, cognition, and behavior. Additionally, to our knowledge, suicidal and self-harm ideation (SSI) has never been mentioned and studied. This study was aimed to give a timely profile, detect the risk and protective factors, and provide some directional suggestions about the implementation of a psychological intervention for hospital workers during and after the COVID-19 epidemic.

This was a cross-sectional study using an online survey based on a specified psychological screening platform, Chongyixinli. Data was conducted from February 14 to 23, 2020, three to four weeks after the COVID-19 epidemic outbreak in Chongqing (Chongqing People's Government, 2020).

We included that hospital workers who were on the job, worked in the 48 Hospitals mentioned above, confirmed the informed consent, and completed the whole questionnaire. This study excluded hospital workers who did not belong to the 48 hospitals. The completeness and logistic errors were also be checked.

This study was carried out under the cooperation between our team and Chongqing Health Committee following the introduction of an emergency psychological crisis intervention in the COVID-19 epidemic promulgated by the National Health Commission of China on January 27, 2020 (National Health Commission of China, 2020). At the beginning of the epidemic outbreak, Chongqing Health Committee assigned 48 hospitals to treat COVID-19 patients. All the participants were recruited from these hospitals, which were classified three levels in this study: 4 designated hospitals were in charge of all the confirmed patients; 16 main district hospitals located in the urban center area; 30 county hospitals located in the rural area. Hospital workers were encouraged by administrative guidance to finish the online survey voluntarily by scanning a QR-code shared in their workgroup in the WeChat application after confirming the informed consent. The results were analyzed automatically on a specialized psychological assessment platform. Finally, workers from 46 hospitals completed the survey. Data protection was declared in the informed consent that all the data only could be used for research in population level. Private data can be protected unless it showed high mental risk (PHQ-9>=15 or positive SSI) and need further professional evaluation and intervention. This study conformed to the ethical guidelines of the 1975 Declaration of Helsinki and got the ethics approval authorized by the Ethics Committee of Chongqing Medical University.

This survey was implemented by using a structured questionnaire that included four domains, sociodemographic features, epidemic-related factors, psychological outcomes, and the source of stress and support. Sociodemographic features included age, gender, nationality, marital status, educational background, career class, profession, employment year, clinical department, level of hospital, frontline department, and SARS experience. The epidemic-related factors included epidemic-related attitudes and behaviors, such as "Please evaluate the possibility of you being infected.", "Are you willing to work in a COVID-19 ward?", "Are you concerned about the progress of the COVID-19 pandemic?", "Do you have confidence about your country defeating COVID-19?", "Please estimate how long you think COVID-19 would last in China.", "Please estimate your health condition during COVID-19.","Did you require the services from a psychological profession before/during COVID-19?", "Is it necessary for healthcare workers to regularly participate a face-to-face or group psychological therapy during this epidemic?", "How did you moderate your emotion while feeling obvious depression or anxiety?", and "Are you still willing to attend parties with many people during the epidemic?".

The Patient Health Questionnaire (PHQ-9) (Spitzer et al., 1999), a five-point Likert-type scale from "not at all" (score 0) to "extremely" (score 4) were used to detect how often the participants had been bothered by depression over the past two weeks. The total score of the PHQ-9 ranged from 0 to 27. Scores of 5, 10, 15, and 20 are taken as the cut-off points for minimal, mild, moderate, moderately severe, and severe depression, respectively. A cut-off score of 7 or higher on the PHQ-9 has a sensitivity of 0.86 and a specificity of 0.86 in the general Chinese population (Wang et al., 2014) . The severity of anxiety was evaluated by the Generalized Anxiety Disorder 7-item Scale (GAD-7) (Spitzer et al., 2006) . The GAD-7 score was calculated by assigning scores of 0, 1, 2, and 3, to the response categories of "not at all", "several days", "more than half the days", and "nearly every day", respectively, and adding together the scores for the seven questions. Scores of 5, 10, and 15 are taken as the cut-off points for mild, moderate, and severe anxiety, respectively. A cut-off score of 10 on the GAD-7 had a sensitivity of 0.86 and a specificity of 0.96 in Chinese general hospital outpatients (He et al., 2010) . The Patient Health Questionnaire, a somatic symptom severity scale (PHQ-15) was employed to assess the severity of somatic symptoms (Kroenke et al., 2002) . The internal consistency coefficient of PHQ-15 is 0.73, and the test-retest reliability coefficient was 0.75 in Chinese general hospital outpatients (Qian J, 2014) . The scale consists of 15 items that ask whether somatic symptoms, such as stomach pain or dizziness, were present in the last four weeks with varying levels of severity (response categories of "not bothered at all," "bothered a little," and "bothered a lot"). The PHQ-15 scores of 5, 10, and 15 represent cut-off points for levels of the low, medium, and high symptom severity, respectively. In this study, high-level depressive, anxiety, and somatic symptoms were defined as a score equal to or more than 10 on PHQ-15, GAD-7, and PHQ-9.

An eighteen-item stress source scale and a six-item support source scale that originated from a survey on frontline healthcare in Taiwan province during SARS (Tam et al., 2004) were reformulated and used in this study (more details are provided in the appendix supplementary). In the stress source scale, five initial items including "Lack of feedback of senior", "Being blamed for mistakes", "Lack of appreciation at work", "Hospital service restructuring, uncertain job prospect", and "Public had high expectations of medical professions" were changed into four current items including "Did you work in the isolated ward?", "Did you directly contact confirmed patients?", "Did your family member or relative get infected?", and "Did your community member get infected?". For convenience, the options were adapted for a "yes" or "no". There were two items originated from Tam 

Data were analyzed using SPSS version 25.0 (SPSS, Chicago, IL, USA). Chi-square (χ2) test was used to compare the differences in categorical variables. T-test was used to compare the differences in continuous variables. Kruskal-Wallis test and Mann-Whitney test were conducted to examine the differences in rating variables. Logistic regression analysis (forward LR) was used to detect independent factors for psychological outcomes and SSI. P< 0.05 was considered statistically significant (two-sided test).

There were 8817 questionnaires after excluding 913 questionnaires for incompletion of the survey (447), non-hospital workers (231), non-local hospitals (158), systematic duplication (29) , and logistic errors (48) (younger than 18 years or the difference between age and employment year less than 18).

The profile of sociodemographic features and epidemic-related factors are listed in Table 1 . The mean value and standard deviation of age, employment year, stress score, and support score were 33.25±8.257, 10.23±8.435, 7.90±2.921, and 3.55±2.644, respectively. The median was considered as the cut-off point for age (31) and employment year (5).

[ Table 1 ]

The results of the PHQ-9 GAD-7, PHQ-15, and SSI are listed in Table 2 . The percentage of high-level depression, anxiety, and somatic symptoms in hospital workers during the COVID-19 epidemic were 9.4%, 5.1%, and 19.8%, respectively. The prevalence of SSI was 6.5%.

[ Table 2] High-level symptoms, SSI, and the stress and support source were compared separately in different sociodemographic and epidemic-related groups. Depression, anxiety, and somatic symptoms were found significantly different among hospital workers with various sociodemographic characteristics, especially the level of hospital and educational background (P<0.05). The lower the educational background was, the higher percentage of depressive, anxiety, and somatic symptoms were (Table 3) .

Meanwhile, SSI and mean value of stress and support sources were significantly different in the groups of epidemic-related attitudes and behaviors. Hospital workers who were working in frontline departments, unwilling to work in COVID-19 ward, unconfident about defeating COVID-19, in need of psychological assistance before or during the epidemic, and admitting regular psychological intervention during the epidemic got more stress, less support, and SSI (P<0.05). (Table 4a and Table   4b ). Note that, except SSI, county hospital workers showed various psychological impact, higher epidemic-related stress, and less support, as compared with those in designated or main district hospitals (P<0.05).

[ Table 3 ]

[ Forward LR logistic regressive analysis was conducted. In the PHQ-9 model, nationality, marital status, educational background, level of hospital, and employment years were included. In the PHQ-15 model, gender, nationality, educational background, level of hospital, and profession were included. In the SSI model, self-rated health condition, self-rated infection possibility, the willingness of attending parties, concern about COVID-19, confidence about defeating COVID-19, lasting time of COVID-19, and previous and current need of psychological intervention were included, with adjustment of stress, support, frontline department, the willingness of working in COVID-19 ward, and necessary of regular psychological intervention (Table 5) [ Table 5 ]

As the most severe public health crisis in the recent half-century, COVID-19 pandemic has affected emotion, body, cognition, and behavior among hospital workers ( Zhang et al., 2020) . This survey was conducted three to four weeks after the COVID-19 outbreak in Chongqing, which was a duration when four mixed reactions of individuals facing disasters: relieved soon, proportionately distressed, disproportionately distressed, and mentally disordered (Williams et al.,2014) . Furthermore, a previous study found 13% of hospital workers used alcohol to cope with the upset feelings experienced in SARS (Vyas et al., 2016) . The hospital workers who preferred more adventurous behavior such as attending parties with many people, although this was not encouraged by government and medical guidance, got a higher stress score and a lower support score in this study. According to the mechanism of allostatic overload, the unexpected, fast spread, and highly infectious virus broke the balance of neuro-endocrine-immune network, which based on the interaction of genes, personality traits, and environmental factors, hence formulated an allostatic load or overload on hospital workers and aroused their cognitive and affective responses.

Adequate coping could lead to a new homeostatic balance. Otherwise, the impairment occurred (W. study. This result provided evidence that the stressful public health crisis was more likely to affect hospital workers' cognition and behavior directly.

The unique factor in this study, which was ignored previously but showed a broad spectrum of influence on hospital workers under the contagion, was the level of hospital. As we previously predicted, workers in the designated hospital would have the most emotional and physical symptoms and the highest perceived pressure, followed by those in the main district hospitals and county hospitals.

The reason was that designated hospitals received almost all the confirmed COVID-19 patients, while the main district hospitals received mostly the patients with non-infected diseases, and county hospitals were far away from the center of the epidemic. Unexpectedly, county hospital workers presented high-level depression, anxiety, and somatic symptoms, which almost as many as designated hospital workers. Moreover, they had the highest stress score and the lowest support score. Two reasons may explain these findings. First, previous studies have shown that frontline hospital workers suffer heavy workload, quarantine, direct contact with confirmed patients, and inconvenience brought by personal To our best knowledge, this is the first study on the prevalence of SSI in hospital workers during a public health crisis. Similar to perceived stress and support, SSI in hospital workers was significantly different in epidemic-related groups. Previous studies found a history of mental disorder as a risk factor for psychological impact in hospital workers (Kisely et al., 2020) . Considering that the percentage in hospital workers who ask for professional psychological assistance was less than 1%, it is reasonable to suspect many hospital workers had already had psychological problems before the epidemic. According 

This study made a timely assessment of the psychological status in a large number of hospital workers, with the use of standardized online questionnaires to make an accurate comparison with other studies. We found various sociodemographic and epidemic-related factors for emotional and physical impacts, perceived stress and support, and SSI. We also give some practical advice to reduce the effect of the COVID-19 epidemic on hospital workers.

First, this cross-sectional study cannot reveal the causality, and voluntary participation may result in selection bias. Second, a modified epidemic-related stress and support questionnaire from the previous studies were used in this study, for there is no standard one for investigation during an epidemic. Third, it was impossible to evaluate the response rate for the unavailable number of hospital workers.

In conclusion, we investigated the psychological status of hospital workers at a city level, and recommend more attention should be paid to county hospital workers, SSI, and perceived stress and support. More studies on cognitive and behavioral subsequence after a public health disaster among hospital workers are needed.

Xu Xiaoming and Ai Ming contributed equally to the article as co-first authors. Xu Xiaoming, Ai We express our gratitudes for the support of the Chongqing Health Commission. 

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We thank Elsevier and English professor Wang Yan from Chongqing Medical University for providing language help. We wish to thank all the hospital workers for protecting public wellness against COVID-19.

The authors declare that there is no conflict of interest.